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241. Communication and Optimal Resolution (CANDOR) Toolkit Module 3: Preparing for Implementation: Change Readiness and Gap Analysis
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/module3-assessment-change-readiness-gap-analysis.pptx
     August 25, 2015 - The diagram, developed by Robert Watcher, shows the distinction between adverse events and errors. … Not all adverse events are medical errors and not all medical errors are adverse events. … DO: Explain the diagram to others, and ask others to provide examples of adverse events that are not … errors and errors that are not adverse events. 8 Develop a Measurement Strategy5 WHAT to measure Process … events.”

242. Understanding Omissions of Care in Nursing Homes | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/omissions.html
     October 01, 2019 - Understanding Omissions of Care in Nursing Homes Adverse events and poor health outcomes

243. Early Mobility in the Intensive Care Unit: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/early-mobility-icu-slides.html
     February 01, 2017 - Slide 11: Safety 3 No serious adverse events. … Slide 14: Adverse Events 4 9 patients had 14 adverse event (<1% of activities): Falls to knees … No documented adverse events. 6. Clark DE, Lowman JD, Griffin RL, et al. … Slide 26: Conclusions—Safety Adverse events ranged from agitation to transient physiological events … Adverse events ranged from 2.3 to 8.7 per 100 patients. 3-5 3.

244. Translating Patient Safety Research into Clinical Practice (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Magid.pdf
     January 01, 2004 - Relationship between medication errors and adverse drug events. … Systems analysis of adverse drug events. JAMA. 1995 (274):35–43. 9. … Incidence of adverse events and negligence in hospitalized patients. … Top-priority actions for preventing adverse drug events in hospitals. … The clinical pharmacist’s role in preventing adverse drug events.

245. Return on Investment Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.docx
     January 01, 2013 - The cost of adverse drug events in hospitalized patients. JAMA 1997;277:307-11. … Costs of adverse events in intensive care units. Crit Care Med 2007;35(11)2637-8. Pappas SH. … The cost of nurse-sensitive adverse events. J Nurs Adm 2008;38(5):230-6. … Using patient safety indicators to estimate the impact of potential adverse events on outcomes. … The costs and savings associated with prevention of adverse events by critical care nurses.

246. Module 4: Teamwork and Communication | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-slides.html
     March 01, 2017 - Events Adverse event: An injury to a resident caused by medical intervention rather than by the … events happen. … Slide 29: Disclosure and Apology for Unexpected Adverse Outcomes Immediate Response to an Adverse … Event Next Steps in Responding to an Adverse Event Care for the resident. … Slide 30: How To Communicate About An Adverse Event Speak slowly and use clear language.

247. AHRQ Quality Indicator Tools for Data Analytics | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/qualityindicators/index.html
     January 01, 2025 - hospital level, the QIs are used to support internal quality improvement, monitoring, and assessment of adverse … events related to patient safety. … Patient Safety Indicators (PSIs) help hospitals assess the incidence of adverse events and in-hospital … More specifically, they focus on potential in-hospital complications and adverse events following surgeries … PDIs focus on potentially preventable complications and iatrogenic events for pediatric patients treated

248. AHRQ's Patient Safety Culture Survey Used to Set Baselines for Improvements at Chicago Hospital | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/cquips0609.html
     October 01, 2014 - Importantly, the survey also highlighted that staff were more uncomfortable with filing reports of adverse … events than was previously recognized. … team targeted its initiatives to address three specific dimensions of patient safety: reporting of adverse … events, handoffs and communication, and feedback and awareness of adverse events.

249. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
     August 01, 2022 - Disclosure communication following an adverse event should include answers to the following questions … How will the organization prevent the adverse event from happening to another patient in the future? … It is important that the clinicians and the health care organization apologize for the adverse event, … Apology–say you are sorry for the adverse event in a sincere manner early in the conversation. … The communicator can also note that most adverse events have multiple causes that include a mixture of

250. Table 7B.1 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-section-7b.pdf
     June 02, 2025 - Table VII.B.1 – Distribution of numbers of Chronic Condition Indicators per patient and adverse … events across sites based on GAPPS study analytic sample (n= 3,442) Chronic Condition Indicators … <0.001 3 or more body systems 125 (3.6%) 0.27 <0.001 Table VII.B.2 – Analysis of differences in adverse

251. Final Progress Report: The ED Pharmacist as a Safety Measure in Emergency Medicine (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/fairbanks-report.pdf
     January 01, 2024 - year in the US7; 5% experience potential adverse drug events,8 and 70% of these, or 3.8 million events … drug events (PADEs) and adverse drug events (ADEs) through a retrospective chart review. … The nature of adverse events in hospitalized patients. … Incidence of adverse events and negligence in hospitalized patients. … drug events (PADEs) and adverse drug events (ADEs) through a retrospective chart review.

252. Patient Safety Learning Laboratory to Enhance the Value and Safety of Neonatal Interfacility Transfers in a Regional Care Network | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/neonatal-interfacility-transfers-long-desc.html
     January 01, 2025 - events occur in up to 70 percent of pediatric critical care ambulance transports, even if performed … Human factors are the root cause of 67 percent of avoidable adverse events in transport due to communication … events. … Neonatal transport safety metrics and adverse event reporting: a systematic review . … Neonatal transport safety metrics and adverse event reporting: a systematic review .

253. Return on Investment Estimation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/f1_pdi_returnoninvestment.pdf
     January 01, 2013 - The cost of adverse drug events in hospitalized patients. JAMA 1997;277:307-11. … Costs of adverse events in intensive care units. Crit Care Med 2007;35(11)2637-8. Pappas SH. … The cost of nurse-sensitive adverse events. J Nurs Adm 2008;38(5):230-6. … Using patient safety indicators to estimate the impact of potential adverse events on outcomes. … The costs and savings associated with prevention of adverse events by critical care nurses.

254. Final Progress Report: Evaluating safety and quality of tracheal intubation in pediatric ICUs (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/nishisaki2-report.pdf
     January 01, 2025 - Our preliminary single-PICU data documented adverse TI-associated events (TIAEs) occur among >20%. … Discussion: Adverse TI events were common across diverse pediatric ICUs. … Impact of trainee level & provider type on tracheal intubate success & associated adverse events. … Association of vagolytic and ketamine use with tracheal associated adverse events. … Substantial site-level variance exists in adverse tracheal intubation associated events: NEAR4KIDS.

255. CommonSpirit Health Expands CANDOR Toolkit Across Entire Health System | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/202104.html
     October 01, 2021 - CommonSpirit Health clinicians have communicated promptly and candidly with patients about an adverse … event or potential adverse event, and officials estimate 85 patients were spared the additional harm … “It’s all about how to communicate an adverse event or a potential adverse event promptly and candidly … However, “We’re never looking at events or other hard data to substantiate our position. … “CANDOR is absolutely the right approach for all involved in an adverse event,” Pelletreau said.

256. Using Six Sigma® Methodology to Improve Handoff Communication in High-Risk Patients (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Mistry_114.pdf
     May 05, 2008 - Meliones MD, MS Abstract Background: During the analyses of adverse events, a commonly described … These patients are at increased risk for adverse events because of the complexity of their diagnosis … Understanding adverse events: Human factors. Qual Health Care 1995; 4: 80-89. 5. Reason J. … The nature of adverse events in hospitalized patients. … Understanding and responding to adverse events. N Engl J Med 2003; 348: 1051-1056. 16.

257. Science of Safety and Identifying Defects in Care of Mechanically Ventilated Patients: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/cusp/science-of-safety-fac-guide.html
     February 01, 2017 - events. … What are safety events in the clinical area? What systems may have led to the events? … events resulting in harm. … Adverse event reporting systems are common in hospitals. … Slide 17: Staff Safety Assessment Say: Adverse reporting systems, sentinel events, and claims data

258. Special Considerations for Measurement of Diagnostic Safety (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/issue-briefs/state-of-science-2b.html
     June 01, 2020 - mindful of its limitations for a given purpose. 40 For instance, many routinely recorded discrete events … communication differences, will also need to be addressed to make the most of such efforts. 59,61,62 Real-time adverse … records is through the “trigger” approach, which aims to “alert patient safety personnel to possible adverse … events so they can review the medical record to determine if an actual or potential adverse event has … research has examined the predictive validity of NLP algorithms for detection of safety incidents and adverse

259. Declines in Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/infographics/hac-rates_2019.html
     July 01, 2020 - (PDF, 11.1 MB) Text Description: National efforts to reduce hospital-acquired conditions such as adverse … drug events and injuries from falls helped prevent 20,700 deaths and saved $7.7 billion between 2014 … Specific rates are: Adverse drug events: 28% decrease. CAUTI: 5% decrease. CLABSI: 6% decrease. … Obstetric events: 3% decrease. Pressure ulcers: 6% increase. Surgical site infections: 8% increase.

260. Making Information Technology a Team Player in Safety: The Case of Infusion Devices (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Nemeth.pdf
     January 01, 2002 - Adverse events including device- related deaths and serious injuries must be reported to the FDA and … How do existing incident reports help to describe adverse events in terms of infusion device programming … Our study’s initial findings give us the opportunity to better understand actual adverse events that … It is possible that practitioners who are involved in adverse events that are reported in the MAUDE … The methods described provide a useful basis for study the evolution of adverse events.